Keywords
rehabilitation - radiology - deglutition disorders - laryngectomy - quality of life
Introduction
Supracricoid laryngectomy (SCL) is an open partial surgery indicated for tumors in
moderately advanced stages and has significantly reduced the indications for surgeries
with a higher degree of mutilation, such as total laryngectomy.[1]
[2]
[3] It is a procedure that can also be indicated for rescue surgeries, with good cancer
control.[4]
Supracricoid laryngectomy consists of the removal of the pedicle from the epiglottis,
thyroid cartilage, laryngeal ventricles, vocal folds, ventricular bands, of the paraglottic
space and the pre-epiglottic space. To enable the formation of the neoglottis, one
or both cricoarytenoid units, the epiglottis and cricoid, must remain. Surgical reconstruction
occurs, among variations, through cricohioidoepiglotopexia (CHEP), in which a suture
is performed between the remaining structures (cricoid cartilage, epiglottis and hyoid
bone).[5]
[6] Cricohioidoepiglotopexia elevates the laryngeal complex to the level of the hyoid
bone, causing a structural rearrangement in the pharyngeal recesses and modification
of the swallowing process.[6]
[7]
Supracricoid laryngectomy CHEP can be classified as a type IIa partial open horizontal
laryngectomy, according to the nomenclature proposed in 2014 by the European Laryngological
Society.[4]
[8] The main functional consequence is a chronic sequel in the closure of the airways
that leads to dysphonia and dysphagia.[1]
[2]
[7]
[8] Dysphagia, due to its potential to cause greater morbidity and morbidity, generally
receives greater clinical and scientific attention. Many authors have described persistent
aspiration in the postoperative period, a fact that generates attention on the long-term
consequences of this chronic dysfunction.[8]
[9] Dysphagia may be associated with a higher risk of pneumonia, less oral intake, more
time to use a nasogastric tube (NGT), weight loss, changes in social activities and,
consequently, worse quality of life (QoL).[2]
[3]
[7]
[9]
An experienced multidisciplinary team is necessary so that the patient can have an
adequate clinical course with the adequacy of the swallowing function from 3 to 6
months after surgery. Despite this consensus, it is known, through imaging exams,
that the safety and efficiency of swallowing are severely compromised. It is possible
to detect long-term chronic aspiration, especially with liquids, and the formation
of residues after swallowing.[7]
[9]
There are different methods to assess dysphagia and its impact, including clinical,
instrumental, and QoL protocols.[2]
[9] Finding an ideal measure for research purposes is challenging due to the complex
physiology of swallowing and its association with food and diet. In recent years,
QoL has become an increasingly important parameter in cancer treatment decisions.
In patients with head and neck cancer, treatment can have a profound impact on QoL.[10] Therefore, long-term QoL has become an important endpoint, along with conventional
survival endpoints.[11]
Currently, videofluoroscopy is the gold-standard test to assess swallowing dynamics.[9] The Penetration and Aspiration Scale (PAS) was developed in 1996 by Rosenbek et
al. in an attempt to categorize the severity of dysphagia, through the identification
of aspiration and penetration in the videofluoroscopic swallowing study (VFSS).[12] Swallowing analysis was based on the description of the presence or absence of aspiration
for years in numerous studies, and safety was the only indication of good swallowing.[13]
Recently, the study of dysphagia has turned to other aspects besides safety. Currently,
it is known that efficiency can have a negative impact equal to or greater than safety
(penetration and aspiration) in functional and QoL criteria. Aspiration in late post-SCL
individuals usually occurs in a chronic and silent form and, therefore, does not present
itself as a common complaint or with relevance in its oral intake.[7]
[8]
[9] The presence of residue (swallowing efficiency), resulting from structural changes
in the surgery, makes it difficult to progress food consistency, promotes the sensation
of stopped food, suffocation, discomfort and damages QoL.[9]
[14]
Unfortunately, residue analysis is still a dilemma in the VFSS from the three-dimensional
(3D) characteristic of pharyngeal recesses. Some studies have attempted to assess
the presence of the residue, with methodological heterogeneity and impaired reproducibility.[9]
[14]
[15]
[16]
[17]
Meyers et al., in 2017, described QoL in a heterogeneous group of 168 head and neck
cancer survivors, and concluded that aspiration and residue show independent effects.
The authors describe that the residue has a greater impact on QoL than the aspiration
event, standing out as a primary measure of swallowing function. Compared with other
methods, the measurement of the residue in this study also has a difficult reproducibility.[14]
Specifically in SCL-CHEP, there are reports in the literature that demonstrate a good
overall QoL.[3]
[9] In a 2018 study, Pizzorni et al. used Fiberscope Endoscopic Evaluation Swallowing
(FEES) in an attempt to understand the association between swallowing function and
QoL after SCL-CHEP. They describe that QoL was significantly affected by the severity
of aspiration; however, they conclude that the perception of the patient was not sufficient
to detect the severity of his dysphagia. This finding suggests that there may be an
incompatibility between the assessment technique and the impact of the function on
the patient.[9]
The formation of residues after SCL-CHEP and its consequences is still poorly described.
In a recent 2019 study, there is a report that the formation of the residue is justified
by increased pharyngeal transit time, reduced opening of the upper esophageal sphincter,
and incomplete retraction of the base of the tongue.[7] There are still no studies that assess the influence of residue on QOL.
In 2017, Hutcheson et al. developed a new tool for analyzing the VFSS. The Dynamic
Imaging Grade of Swallowing Toxicity (DIGEST) scale offers an ordinal summary of five
points to standardize the report and description of the bolus passage through the
pharynx, and brings an assessment that considers safety, using PAS, and efficiency,
through analysis of the residue in the VFSS exam.[15] It is a validated tool to assess the severity of pharyngeal dysphagia, which assigns
a value by correlating the parameters of safety and efficiency of swallowing. No studies
were found using this new tool related to aspects of QoL.
The aim of the present study was to analyze the association between QoL and changes
in the safety and efficiency of swallowing detected by the VFSS in patients undergoing
SCL-CHEP. Based on the premise that efficiency is more relevant to QoL than safety,
the strategy of finding new tools that contemplate the impact of dysphagia in a multidimensional
way has become essential.
Methods
Cross-sectional study, approved by the Research Ethics Committee of the institution
under CAAE: 26331314.2.0000.5274, 616.249. Individuals of both sexes submitted to
SCL-CHEP, from the Instituto Nacional de Câncer (Brazilian National Cancer Institute),
were included. Exclusion criteria were patients < 18 years old, uncooperative due
to linguistic-cognitive impairments, and undergoing another type of surgical intervention
in the laryngeal region after SCL-CHEP. All volunteers participating in the present
study signed the consent form.
The individuals eligible for the present study were located in the service from 2018
to 2020. Demographic and clinical information were collected through the analysis
of physical and electronic medical records. For speech therapy and QoL assessments,
the patients were approached and invited to participate in the study and to be submitted
to the procedures described below.
Swallowing Assessment Instruments and Procedures
The VFSS was used to evaluate the swallowing of the research patients. A total of
860 exams were performed using the Siemens AXIOM Iconos Remote Control X-ray equipment
(serial number 13020) (Siemens, Munich, Germany) and were evaluated using a Logemann-based
protocol from 1998.[18] All video segments were recorded in the side view plane, with a capture rate of
30 frames per second.
The contrast was offered in a cup, using 100% dilutions of Bariogel (Cristália, Itapira,
São Paulo, Brazil) barium sulfate (BS), mineral water and the ThickenUp Clear Thickener
Resource (Nestlé Health Science, São Bernardo do Campo, São Paulo, Brazil). Three
consistencies were evaluated: thin liquid in 5 mL (2.5 mL of water + 2.5 mL of BS),
10 mL (5 mL of water + 5 mL of BS) and 20 mL (10 mL of water + 10 mL of BS); semi-liquid
consistency in 5 mL of BS, 10 mL of BS and 20 mL of BS; and pasty consistency in 5 mL
(5 mL of BS + 1.2 g of thickener), 10 mL (10 mL of BS + 2.4 g of thickener) and 20 mL
(20 mL of BS + 3.6 g of thickener). To standardize the exam, solid consistency was
not included, since some individuals have dental absences. The PAS[12] and the DIGEST[15] were used to analyze the VFSS.
The DIGEST is a validated staging tool to assess the severity of pharyngeal dysphagia
based on the study of the VFSS. The scale first assigns two component scores: 1) safety
rating, and 2) efficiency rating. To classify safety, the evaluator must assign the
PAS scale score observed during the swallowing of different consistencies of the bolus,
according to the VFSS protocol performed.[12]
[18] To estimate the efficiency rating, the evaluator assigns a maximum percentage of
pharyngeal residue on an ordinal scale (< 10%; 10 to 49%; 50 to 90%; and > 90%), to
assign a residue pattern after the first swallow. The DIGEST offers an ordinal summary
of 5 points that assigns a value by correlating the parameters of safety and efficiency
of swallowing: grade 0 = without dysphagia; 1 = mild dysphagia; 2 = moderate dysphagia;
3 = severe dysphagia; 4 = life-threatening.[15]
Quality of Life Assessment
The only tool available to assess the effects of swallowing changes on QoL in individuals
undergoing treatment for head and neck cancer is the M. D. Anderson Dysphagia Questionnaire
(MDADI), developed and validated by Chen et al. in 2001.[19] The tool was validated for Brazilian Portuguese by Guedes et al. in 2013[20] and consists of 20 questions, on the global, emotional, functional and physical
domains. All scales have 5 possible responses, ranging from 1 (strongly agree) to
5 (strongly disagree), except 1 item from the emotional subscale (E7) and 1 item from
the functional subscale (F2), which are scored varying from 5 (strongly agree) to
1 (strongly disagree). The score for each subscale is obtained by calculating the
average score of its items, multiplied by 20. The total score is obtained from the
average of the scores for each domain (emotional, functional and physical) multiplied
by 20. The individual can obtain a score ranging from 0 to 100, and the lower the
value of the observed score, the worse the effect of dysphagia in their QOL and functionality.[2]
[19]
Statistical Analysis
The data were analyzed using STATA software, version 13.0 (StataCorp, College Station,
TX, USA). Quantitative variables were described as mean and standard deviation (SD)
or median and minimum and maximum, and qualitative variables were expressed in absolute
and relative frequency. The normality of the data was analyzed using the histogram
and the Kolmogorov-Smirnov test. The Student t-test and analysis of variance (ANOVA) were applied to compare means, and Pearson
linear correlation was applied to verify a possible correlation between variables.
The significance level of 5% (p < 0.05) was adopted for all statistical tests.
Results
A total of 86 patients were evaluated, with a mean age of 61.4 (±9.55) years old and
a median of 62 years old, ranging from 28 to 82 years old. There was a higher prevalence
of males (n = 84; 97.67%), married (n = 61; 70.93%), with low education (up to elementary school) (n = 52; 60.47%), smokers (n = 72; 83.72%) and alcoholics (n = 71; 82.56%) at diagnosis and with intermediate or advanced stage laryngeal tumors
(n = 82; 95.35%) of histopathological squamous cell carcinoma (n = 85; 98.83%) ([Table 1]).
Table 1
Characterization of 86 patients undergoing supracricoid laryngectomy with reconstruction
using cricohioidoepiglotopexia
|
Variables
|
N
|
%
|
|
Age (years old) [a]
[b]
|
|
61.4 (9.55)
|
62 (28–82)
|
|
Sex
|
Female
|
2
|
2.32
|
|
Male
|
84
|
97.67
|
|
Marital status
|
Single
|
25
|
29.07
|
|
Married
|
61
|
70.93
|
|
Educational level
|
Elementary School
|
52
|
60.47
|
|
High school and higher education
|
34
|
39.53
|
|
Smoker
|
Yes
|
72
|
83.72
|
|
No
|
14
|
16.28
|
|
Alcohol consumption
|
Yes
|
71
|
82.56
|
|
No
|
15
|
17.44
|
|
Arytenoid
|
1
|
29
|
33.72
|
|
2
|
57
|
66.28
|
|
Oncological staging
|
II
|
53
|
61.63
|
|
III
|
29
|
33.72
|
|
IV
|
4
|
4.65
|
|
Adjuvant radiotherapy
|
Yes
|
61
|
70.93
|
|
No
|
25
|
29.07
|
|
% Emotional [b]
|
|
100
|
(46.65–100)
|
|
% Functional [b]
|
|
100
|
(32–100)
|
|
% Physical [b]
|
|
83.75
|
(47.5–100)
|
|
% Global [b]
|
|
100
|
(20–100)
|
|
% Total [b]
|
|
94.60
|
(45.12–100)
|
|
DIGEST [b]
|
|
2
|
(1–4)
|
|
PAS [b]
|
|
5
|
(2–8)
|
Abbreviations: DIGEST, Dynamic Imaging Grade of Swallowing Toxicity; N, number; %,
frequency; PAS, Penetration- Aspiration Scale.
a = Mean / standard deviation
b = Median / minimum and maximum.
All individuals underwent SCL-CHEP; most of them had 2 arytenoids in their neoglot
(n = 57; 66.28%), ∼ 71% (n = 61) underwent adjuvant radiotherapy, only 3 patients (3.48%) presented wound infections
in the postoperative period, and 1 (1.16%) patient presented cervical fistula. There
was no necrosis or hemorrhage, no patient had pneumonia at the time of the study.
There is no permanence of NGT in the evaluated group, that is, all had exclusive orally
food and hydration at the time of the evaluation. Only 3 patients remained with a
tracheostomy (3.48%).
The QoL in swallowing, obtained through the MDADI questionnaire, was presented with
medians of values > 80 in all domains. The emotional, functional and global domains
obtained the best medians of the scores, presenting the maximum value. The lowest
median value was in the physical domain. The emotional domain had a mean of 96.09
(±9.35), and a median of 100, with a range of 46.65 to 100. The functional domain
had a mean of 92.36 (±12.15), and a median of 100, with a range of 32 to 100. The
physical domain had an average of 82.32 (±11.59), and a median of 100 with a range
of 47.5 to 100. The global domain had an average of 92.55 (±17.09), and a median of
100 with a range of 20 to 100. The total domain had a mean of 89.33 (±10.92), and
a median of 100 with a range from 45.12 to 100 ([Table 1]).
The most prevalent classification on the DIGEST scale was DIGEST 2 (n = 45; 52.32%), followed by the DIGEST 1 (n = 30; 34.88%), 3 (n = 9; 10.46%) and 4 (n = 2; 2.32%). In the PAS scale, the classification with the highest appearance was
PAS 5 (n = 46; 53.48%), followed by number 8 (n = 25; 29.06%), 4 (n = 14; 16.27%) and 2 (n = 1; 1.16%).
[Table 2] indicates the correlation between the domains of the MDADI questionnaire and the
DIGEST and PAS scales. It was possible to observe a negative correlation between the
DIGEST and the emotional domain of the QoL protocol (p = 0.045), that is, the higher the QoL score, the lower the DIGEST classification.
Table 2
Distribution of the domains of the M. D. Anderson Dysphagia Questionnaire (MDADI -
M. D. Anderson Dysfaghia Inventory) in relation to the swallowing functional performance
represented by the DIGEST and PAS scales
|
Domains MDADI
|
DIGEST
|
PAS
|
|
r
|
p-value
[*]
|
r
|
p-value[*]
|
|
Emotional
|
− 0.216
|
0.045
|
0.057
|
0.605
|
|
Functional
|
− 0.083
|
0.446
|
0.142
|
0.191
|
|
Physical
|
− 0.171
|
0.116
|
− 0.061
|
0.578
|
|
Global
|
− 0.141
|
0.196
|
− 0.021
|
0.846
|
|
Total
|
− 0.180
|
0.097
|
0.031
|
0.774
|
Abbreviations: DIGEST, Dynamic Imaging Grade of Swallowing Toxicity; PAS, Penetration-
Aspiration Scale.
* Pearson correlation.
[Table 3] describes the statistical results of the association between clinical and sociodemographic
variables, the functional swallowing results from the PAS and DIGEST scales, and the
global and total domain of the MDADI questionnaire. There was a significant relation
between staging and the domains of global (p < 0.001) and total QoL (p = 0.002), respectively. Nonsmokers report better global (p = 0.075) and total QoL. Patients with 2 arytenoids had a lower degree of dysphagia
when compared with patients with 1 arytenoid (PAS; p = 0.070).
Table 3
Association of clinical and sociodemographic variables, functional swallowing results,
and the global and total domain of the M. D. Anderson Dysphagia Questionnaire (MDADI
- M. D. Anderson Dysfaghia Inventory)
|
Variables
|
DIGEST
|
PAS
|
Global
|
Total
|
|
Average (SD)
|
p-value
[*]
|
Average (SD)
|
p-value
[*]
|
Average
(SD)
|
p-value
[*]
|
Average
(SD)
|
p-value
[*]
|
|
Age (years old)
|
|
|
|
|
|
|
|
|
|
< 60
|
1.76 (0.60)
|
0.696
|
5.73 (1.52)
|
0.773
|
91.76 (17.83)
|
0.730
|
90.53 (11.45)
|
0.742
|
|
≥60
|
1.82 (0.78)
|
|
5.63 (1.61)
|
|
93.02 (16.75)
|
|
89.72 (10.78)
|
|
|
Sex
|
|
|
|
|
|
|
|
|
|
Male
|
1.80 (0.71)
|
0.102
|
5.67 (1.55)
|
0.768
|
92.38 (17.26)
|
0.536
|
89.88 (11.07)
|
0.399
|
|
Female
|
2.00 (1.41)
|
|
6.00 (2.83)
|
|
100 (0.00)
|
|
96.56 (1.33)
|
|
|
Marital status
|
|
|
|
|
|
|
|
|
|
Single
|
2.00 (0.82)
|
0.102
|
6.12 (1.59)
|
0.092
|
89.60 (20.10)
|
0.307
|
87.59 (13.37)
|
0.188
|
|
Married
|
1.72 (0.66)
|
|
5.49 (1.53)
|
|
93.77 (15.72)
|
|
91.04 (9.80)
|
|
|
Educational level
|
|
|
|
|
|
|
|
|
|
Elementary School
|
1.79 (0.61)
|
0.825
|
5.63 (1.53)
|
0.773
|
90.77 (19.59)
|
0.232
|
89.32 (12.42)
|
0.455
|
|
High school and higher education
|
1.82 (0.87)
|
|
5.73 (1.64)
|
|
95.29 (12.12)
|
|
91.14 (8.38)
|
|
|
Smoker
|
|
|
|
|
|
|
|
|
|
Yes
|
1.76 (0.66)
|
0.262
|
5.60 (1.52)
|
0.303
|
91.11 (18.35)
|
0.075
|
89.15 (11.68)
|
0.088
|
|
No
|
2.00 (0.96)
|
|
6.07 (1.77)
|
|
100 (0.00)
|
|
94.62 (4.13)
|
|
|
Alcohol consumption
|
|
|
|
|
|
|
|
|
|
Yes
|
1.85 (0.72)
|
0.110
|
5.77 (1.57)
|
0.199
|
92.39 (17.36)
|
0.848
|
89.99 (11.14)
|
0.924
|
|
No
|
1.53 (0.64)
|
|
5.20 (1.52)
|
|
93.33 (16.33)
|
|
90.29 (10.58)
|
|
|
Arytenoid
|
|
|
|
|
|
|
|
|
|
1
|
1.97 (0.78)
|
0.133
|
6.10 (1.52)
|
0.070
|
94.48 (15.94)
|
0.460
|
91.32 (9.09)
|
0.442
|
|
2
|
1.71 (0.67)
|
|
5.46 (5.04)
|
|
91.58 (17.71)
|
|
89.39 (11.85)
|
|
|
Adjuvant radiotherapy
|
|
|
|
|
|
|
|
|
|
Yes
|
1.92 (0.81)
|
0.332
|
5.59 (1.53)
|
0.439
|
96.80 (12.49)
|
0.142
|
92.69 (9.47)
|
0.153
|
|
No
|
1.75 (0.67)
|
|
5.88 (1.67)
|
|
90.82 (18.47)
|
|
88.95 (11.45)
|
|
|
Oncological staging
|
|
|
|
|
|
|
|
|
|
II
|
1.71 (0.69)
|
0.777
|
5.57 (1.63)
|
0.121
|
95.09 (11.02)
|
<0.001
|
91.12 (8.27)
|
0.002
|
|
III
|
2.00 (0.75)
|
|
6.00 (1.49)
|
|
89.65 (23.07)
|
|
90.07 (12.19)
|
|
|
IV
|
1.50 (0.58)
|
|
4.75 (5.00)
|
|
80 (28.28)
|
|
75.47 (23.32)
|
|
Abbreviations: DIGEST, Dynamic Imaging Grade of Swallowing Toxicity; PAS, Penetration-
Aspiration Scale; SD, standard deviation.
* Student t-test for dichotomous variables and ANOVA for nondichotomous variables.
[Figs. 1] and [2] were obtained by analyzing all the domains of the MDADI questionnaire in relation
to each classification in the functional scales of swallowing PAS and DIGEST. It is
possible to visualize the influence of swallowing functionality under the aspect of
severity of each scale and its impact on the QOL of individuals.
Fig. 1 Boxplot of the distribution by domain of the Swallowing Quality of Life Questionnaire
M. D. Anderson Dysfaghia Inventory (MDADI) in relation to each classification from
the Penetration and Aspiration Scale (PAS).
Fig. 2 Boxplot of the distribution by domain of the Deglutition Quality of Life Questionnaire
M. D. Anderson Dysfaghia Inventory (MDADI) in relation to each classification from
the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST).
It is observed in [Fig. 1] that the lowest value of total QoL was found in PAS 4 with an average value of 88.57
(median of 93.15; SD = 9.21), ranging from 51.83 to 97.5; and the highest total QoL
was at PAS 2 of 96.5, in which only 1 patient was present. The lowest QoL value in
all PAS classifications was present in the physical domain, with a median of 90 in
PAS 2; 77.5 in PAS 4; 85 in PAS 5; and 82.5 in PAS 8. The highest QoL value in all
PAS classifications was present in the functional domain with a median of 96 in PAS
2; 100 in PAS 4; 98 in PAS 5; and 100 in PAS 8. It is not possible to observe in [Fig. 1] a progression in increasing QoL according to the best performance in the PAS swallowing
scale.
It is possible to observe in Fig. 2 a progression of QoL according to the best performance
on the DIGEST swallowing scale; the better the functional result in this scale, the
better the result of the MDADI questionnaire. The lowest value of total QoL was found
in DIGEST 4, with an average value of 71.62 (median of 71.60; SD = 14.8). The best
average total quality of life in DIGEST 1 was 94.66 (median 95.5; SD = 6.88), ranging
from 51.83 to 100. The lowest QoL value in all classifications of the DIGEST was present
in the physical domain, with a median of 83.75 in DIGEST 1; 85 in DIGEST 2; 82.5 in
DIGEST 3; and 62.5 in DIGEST 4. The highest QoL value in all DIGEST classifications
was present in the functional domain, with a median of 100 in DIGEST 1; 100 in DIGEST
2; 96 in DIGEST 3; and 84 in DIGEST 4.
Discussion
The aim of the present study was to investigate the possible association between self-reported
QoL and the objective assessment of swallowing performed by VFSS and to test, for
this purpose, the use of two scales, PAS and DIGEST, in patients undergoing SCL-CHEP.
There was a prevalence of males, married, with low education, smokers and alcoholics
at diagnosis and with intermediate or advanced stage laryngeal tumors of histopathological
squamous cell carcinoma, a group consistent with the population commonly described
for head and neck cancer.[1]
[2]
[3]
[4]
[7]
[8]
In patients with head and neck cancer, swallowing disorders are common, caused by
the development of the disease in anatomical sites such as the oral cavity, the pharynx
and the larynx, or by the treatment of adjacent structures.[21] The investigation of QoL in swallowing makes it possible to identify the damages
that dysphagia can cause in activities of daily living, mood, social limitations,
and enable the best therapeutic intervention.[2]
[3]
[9]
[21] Quality of life protocols are tools that assist clinicians in building an individualized
and contextualized rehabilitation.[22]
At the time of the clinical evaluation of swallowing, all patients had exclusive oral
feeding and hydration. However, through the PAS and DIGEST scales, it is possible
to understand some limitations in this function. In the classification on the DIGEST
scale, there was a high prevalence of grades 1 and 2 (87.2%) in the sample, suggesting
that most patients had mild or moderate dysphagia. It is important to consider that
there was no patient classified as DIGEST 0 (without dysphagia), making evident the
characteristic of chronic dysphagia due to a surgical sequel, already described in
the literature.[7]
[9]
[13]
[21] Approximately 13% of the individuals presented moderate or severe impairment of
swallowing function, even at a late postsurgical moment, a fact that reinforces the
long-term monitoring of patients. Swallowing may be influenced by other aspects, such
as aging and several comorbidities.[2]
[8]
In the clinical evaluation of swallowing using PAS, a higher prevalence of PAS 5 and
8 was observed, with a total of 82.54%. The lowest frequency ratings were 4 and 2
(n = 15; 17.43%). This data probably does not represent the reality of the QoL of the
patients, due to PAS considering only penetration and aspiration in its severity classification.
A different distribution was observed in the DIGEST, with a higher prevalence of more
severe dysphagia. Supracricoid laryngectomy CHEP removes ∼ 70% of the organ, its resection
and reconstruction promote important functional and structural changes that may lead
to the formation of residues and impair the protection of the lower airways.[5]
[7]
[9]
[13] In the long term, aspiration becomes chronic, and this functional adaptation reduces
the impact on QoL due to its silent characteristic.[9] This fact agrees with the large number of patients with good QoL in the MDADI questionnaire.[3]
[9]
[23] There is a more severe group, with worse efficiency results, in which the presence
of pharyngeal residue usually causes complaints of the sensation of stopped food,
suffocation, and difficulty in progressing the diet.[7]
[14]
[15]
[21] Therefore, it is possible to understand why the DIGEST results are more consistent
with QoL scores.
Only three patients remained with a tracheostomy, an aspect that was not significant
for this assessment of QoL; however, it is clear that it may affect their daily activities
in some way. Tracheostomy has several social stigmas and requires daily management
to maintain hygiene and minimize the risk of infection.[24]
More advanced cancer stages showed a significant relationship with the global and
total domains in the MDADI questionnaire. This finding reinforces that early detection
is the main way of maintaining the structures, the laryngeal functions and the QoL
of patients with head and neck cancer.[2]
[25]
The main objective of cancer treatment is the control of the tumor with the maintenance
of functions and, in the case of the larynx, the organ responsible for breathing,
swallowing and speech, reaching this goal is a challenge.[5]
[6]
[9]
[13]
[21] The radiotherapy protocols aim to conserve the organ; however, it is known that
the preservation of function is not always achieved, especially in cases of advanced
tumors, causing a negative impact on QoL.[11] Partial laryngectomies aim to be an option for the treatment of moderately advanced
tumors, without the permanence of permanent tracheostomia and preservation of the
laryngeal voice and oral feeding.[1]
[5]
[6]
[9]
[13] However, the maintenance of these functions is not complete and, in the case of
swallowing, the patient remains with chronic dysphagia due to the removal of important
structures for the protection of the lower airways.[7]
[13] Even so, after a few months of therapy, most patients return to feeding exclusively
via the oral route.[7]
[9] Dysphagia is expected to have some impact on the patient, affecting his QoL.[3]
[23]
The assessment of QoLin swallowing presented medians of values > 80 in all domains.
This result demonstrates that the proper selection and management of patients can
generate adequate QoLstandards.[2]
[3]
[9] The average MDADI score for the total domain reported in the literature ranges from
80 to 92, demonstrating a good QoL in this group of patients.[2]
[9] In a recent study, Pizzorni et al. investigated QoL related to swallowing after
SCL-CHEP .and reported that it was significantly affected by the severity of aspiration,
with higher mean scores on the functional subscale of the MDADI questionnaire and
lower scores on the physical subscale.[9] Similar results were observed, with an average total score of 89.33 and with the
same distribution of scores in the subscales, suggesting a long-term QoL.
For a group that is known to have chronic dysphagia, the positive homogeneity of QoL
results leads to consider that there is still a need for tools that consider other
aspects of swallowing dynamics. Other studies have already shown that residue has
a negative impact on the lives of patients with head and neck cancer, and the identification
of an instrument that considers this parameter is essential[14] to improve the assessment and rehabilitation.
Lower averages of MDADI values are consistent with worse swallowing values attributed
by DIGEST, which, despite not having been statistically significant, shows adequate
behavior compared with that observed in the clinic. The results also demonstrated
a negative correlation between the DIGEST and the emotional domain of the QoL protocol,
reinforcing the hypothesis that the efficiency of swallowing could have a relevant
impact on the QoL of these individuals.[9]
[14]
The present study presents a limitation in the reduced number of patients. Further
future assessments with an expanded group in more than one center are required. It
is necessary to find ways of assessing functional changes that are in agreement with
the clinical status and QoL perceptions of the individuals. The result of the functional
scales needs to contemplate the patient in a multidimensional way to enable assertive
interventions. The swallowing function is of great importance for the maintenance
of the life and well-being of the individual; there is no coherence when we describe
a negative finding of a function and there are no impacts on QoL. It is evident that
some aspect is not being contemplated.
In the present study, PAS did not show agreement with QoL. The most severe PAS did
not necessarily represent worse QoL values. It is possible to observe a QoL progression
behavior according to the best performance on the DIGEST swallowing scale. Residue
was a more relevant aspect for QoL, making the DIGEST a promising tool in the assessment
of dysphagic patients.
Conclusion
The DIGEST and PAS did not obtain similar results to assess the swallowing of patients
undergoing supracricoid laryngectomy. The PAS classified swallowing with the highest
severity rates. The DIGEST was more consistent with the QoL assessment. More advanced
oncology stays had a significant relationship with the global and total domains in
the MDADI questionnaire. Medians > 80 were observed in all domains of the MDADI questionnaire,
The appropriate selection and management of patients can generate adequate QOL standards.
There was a reduction in the mean value of MDADI that accompanies the worsening of
the swallowing function attributed by the DIGEST and a negative correlation between
the DIGEST and the emotional domain of the QoL protocol, reinforcing the hypothesis
that swallowing efficiency has a more relevant impact on QoL than just safety.
